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Elms L, Hand B, Skubisz M, Best KP, Grzeskowiak LE, Rogers GB, Green TJ, Taylor SL. The Effect of Iron Supplements on the Gut Microbiome of Females of Reproductive Age: A Randomized Controlled Trial. J Nutr 2024; 154:1582-1587. [PMID: 38521191 DOI: 10.1016/j.tjnut.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/16/2024] [Accepted: 03/13/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Iron deficiency is the most common nutritional deficiency worldwide, particularly for young children and females of reproductive age. Although oral iron supplements are routinely recommended and generally considered safe, iron supplementation has been shown to alter the fecal microbiota in low-income countries. Little is known about the effect of iron supplementation on the fecal microbiota in high-income settings. OBJECTIVES To assess the effect of oral iron supplementation compared with placebo on the gut microbiome in nonpregnant females of reproductive age in a high-income country. METHODS A 21-d prospective parallel design double-blind, randomized control trial conducted in South Australia, Australia. Females (18-45 y) were randomly assigned to either iron (65.7 mg ferrous fumarate) or placebo. Fecal samples were collected prior to commencing supplements and after 21 d of supplementation. The primary outcome was microbiota β-diversity (paired-sample weighted unique fraction metric dissimilarity) between treatment and placebo groups after 21 d of supplementation. Exploratory outcomes included changes in the relative abundance of bacterial taxa. RESULTS Of 82 females randomly assigned, 80 completed the trial. There was no significant difference between the groups for weighted unique fraction metric dissimilarity (mean difference: 0.003; 95% confidence interval: -0.007, 0.014; P = 0.52) or relative abundance of common bacterial taxa or Escherichia-Shigella (q > 0.05). CONCLUSIONS Iron supplementation did not affect the microbiome of nonpregnant females of reproductive age in Australia. This trial was registered at clinicaltrials.gov as NCT05033483.
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Affiliation(s)
- Levi Elms
- Microbiome and Host Health Programme, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia; Infection and Immunity, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Brittany Hand
- College of Nursing and Health Sciences, Flinders University, Bedford Park, South Australia, Australia
| | - Monika Skubisz
- SAHMRI Women and Kids Theme, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia; Discipline of Pediatrics, Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Karen P Best
- SAHMRI Women and Kids Theme, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia; Discipline of Pediatrics, Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Luke E Grzeskowiak
- SAHMRI Women and Kids Theme, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia; College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Geraint B Rogers
- Microbiome and Host Health Programme, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia; Infection and Immunity, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Tim J Green
- College of Nursing and Health Sciences, Flinders University, Bedford Park, South Australia, Australia; SAHMRI Women and Kids Theme, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Steven L Taylor
- Microbiome and Host Health Programme, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia; Infection and Immunity, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia.
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Braat S, Fielding KL, Han J, Jackson VE, Zaloumis S, Xu JXH, Moir-Meyer G, Blaauwendraad SM, Jaddoe VWV, Gaillard R, Parkin PC, Borkhoff CM, Keown-Stoneman CDG, Birken CS, Maguire JL, Bahlo M, Davidson EM, Pasricha SR. Haemoglobin thresholds to define anaemia from age 6 months to 65 years: estimates from international data sources. Lancet Haematol 2024; 11:e253-e264. [PMID: 38432242 PMCID: PMC10983828 DOI: 10.1016/s2352-3026(24)00030-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/25/2024] [Accepted: 01/25/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Detection of anaemia is crucial for clinical medicine and public health. Current WHO anaemia definitions are based on statistical thresholds (fifth centiles) set more than 50 years ago. We sought to establish evidence for the statistical haemoglobin thresholds for anaemia that can be applied globally and inform WHO and clinical guidelines. METHODS In this analysis we identified international data sources from populations in the USA, England, Australia, China, the Netherlands, Canada, Ecuador, and Bangladesh with sufficient clinical and laboratory information collected between 1998 and 2020 to obtain a healthy reference sample. Individuals with clinical or biochemical evidence of a condition that could reduce haemoglobin concentrations were excluded. We estimated haemoglobin thresholds (ie, 5th centiles) for children aged 6-23 months, 24-59 months, 5-11 years, and 12-17 years, and adults aged 18-65 years (including during pregnancy) for individual datasets and pooled across data sources. We also collated findings from three large-scale genetic studies to summarise genetic variants affecting haemoglobin concentrations in different ancestral populations. FINDINGS We identified eight data sources comprising 18 individual datasets that were eligible for inclusion in the analysis. In pooled analyses, the haemoglobin fifth centile was 104·4 g/L (90% CI 103·5-105·3) in 924 children aged 6-23 months, 110·2 g/L (109·5-110·9) in 1874 children aged 24-59 months, and 114·4 g/L (113·6-115·2) in 1839 children aged 5-11 years. Values diverged by sex in adolescents and adults. In pooled analyses, the fifth centile was 122·2 g/L (90% CI 121·3-123·1) in 1741 female adolescents aged 12-17 years and 128·2 g/L (126·4-130·0) in 1103 male adolescents aged 12-17 years. In pooled analyses of adults aged 18-65 years, the fifth centile was 119·7 g/L (90% CI 119·1-120·3) in 3640 non-pregnant females and 134·9 g/L (134·2-135·6) in 2377 males. Fifth centiles in pregnancy were 110·3 g/L (90% CI 109·5-111·0) in the first trimester (n=772) and 105·9 g/L (104·0-107·7) in the second trimester (n=111), with insufficient data for analysis in the third trimester. There were insufficient data for adults older than 65 years. We did not identify ancestry-specific high prevalence of non-clinically relevant genetic variants that influence haemoglobin concentrations. INTERPRETATION Our results enable global harmonisation of clinical and public health haemoglobin thresholds for diagnosis of anaemia. Haemoglobin thresholds are similar between sexes until adolescence, after which males have higher thresholds than females. We did not find any evidence that thresholds should differ between people of differering ancestries. FUNDING World Health Organization and the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Sabine Braat
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Methods and Implementation Support for Clinical and Health research Hub, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Katherine L Fielding
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia; Clinical Haematology, The Austin Hospital, Heidelberg, VIC, Australia
| | - Jiru Han
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Victoria E Jackson
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Sophie Zaloumis
- Methods and Implementation Support for Clinical and Health research Hub, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Jessica Xu Hui Xu
- Methods and Implementation Support for Clinical and Health research Hub, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Gemma Moir-Meyer
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Sophia M Blaauwendraad
- Generation R Study Group, and Department of Pediatrics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Vincent W V Jaddoe
- Generation R Study Group, and Department of Pediatrics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Romy Gaillard
- Generation R Study Group, and Department of Pediatrics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Patricia C Parkin
- Division of Pediatric Medicine and the Pediatric Outcomes Research Team, The Hospital for Sick Children, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Cornelia M Borkhoff
- Division of Pediatric Medicine and the Pediatric Outcomes Research Team, The Hospital for Sick Children, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Charles D G Keown-Stoneman
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Unity Health Toronto, Toronto, ON, Canada
| | - Catherine S Birken
- Division of Pediatric Medicine and the Pediatric Outcomes Research Team, The Hospital for Sick Children, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Jonathon L Maguire
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Unity Health Toronto, Toronto, ON, Canada
| | - Melanie Bahlo
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Eliza M Davidson
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia; Diagnostic Haematology, The Royal Melbourne Hospital, Parkville, VIC, Australia; Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, VIC, Australia.
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Brittenham GM, Moir-Meyer G, Abuga KM, Datta-Mitra A, Cerami C, Green R, Pasricha SR, Atkinson SH. Biology of Anemia: A Public Health Perspective. J Nutr 2023; 153 Suppl 1:S7-S28. [PMID: 37778889 DOI: 10.1016/j.tjnut.2023.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/04/2023] [Accepted: 07/31/2023] [Indexed: 10/03/2023] Open
Abstract
Our goal is to present recent progress in understanding the biological mechanisms underlying anemia from a public health perspective. We describe important advances in understanding common causes of anemia and their interactions, including iron deficiency (ID), lack of other micronutrients, infection, inflammation, and genetic conditions. ID develops if the iron circulating in the blood cannot provide the amounts required for red blood cell production and tissue needs. ID anemia develops as iron-limited red blood cell production fails to maintain the hemoglobin concentration above the threshold used to define anemia. Globally, absolute ID (absent or reduced body iron stores that do not meet the need for iron of an individual but may respond to iron supplementation) contributes to only a limited proportion of anemia. Functional ID (adequate or increased iron stores that cannot meet the need for iron because of the effects of infection or inflammation and does not respond to iron supplementation) is frequently responsible for anemia in low- and middle-income countries. Absolute and functional ID may coexist. We highlight continued improvement in understanding the roles of infections and inflammation in causing a large proportion of anemia. Deficiencies of nutrients other than iron are less common but important in some settings. The importance of genetic conditions as causes of anemia depends upon the specific inherited red blood cell abnormalities and their prevalence in the settings examined. From a public health perspective, each setting has a distinctive composition of components underlying the common causes of anemia. We emphasize the coincidence between regions with a high prevalence of anemia attributed to ID (both absolute and functional), those with endemic infections, and those with widespread genetic conditions affecting red blood cells, especially in sub-Saharan Africa and regions in Asia and Oceania.
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Affiliation(s)
- Gary M Brittenham
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY, United States.
| | - Gemma Moir-Meyer
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Department of Medical Biology, The University of Melbourne, Parkville, VIC, Australia
| | - Kelvin Mokaya Abuga
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Ananya Datta-Mitra
- Department of Pathology and Laboratory Medicine, University of California, Davis, CA, United States
| | - Carla Cerami
- The Medical Research Council Unit, The Gambia, London School of Hygiene and Tropical Medicine, London, UK
| | - Ralph Green
- Department of Pathology and Laboratory Medicine, University of California, Davis, CA, United States
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Department of Medical Biology, The University of Melbourne, Parkville, VIC, Australia; Diagnostic Haematology, The Royal Melbourne Hospital; and Clinical Haematology at the Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, VIC Australia
| | - Sarah H Atkinson
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya; Department of Paediatrics, University of Oxford, Oxford, UK
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Loechl CU, Datta-Mitra A, Fenlason L, Green R, Hackl L, Itzkowitz L, Koso-Thomas M, Moorthy D, Owino VO, Pachón H, Stoffel N, Zimmerman MB, Raiten DJ. Approaches to Address the Anemia Challenge. J Nutr 2023; 153 Suppl 1:S42-S59. [PMID: 37714779 PMCID: PMC10797550 DOI: 10.1016/j.tjnut.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 07/21/2023] [Accepted: 07/31/2023] [Indexed: 09/17/2023] Open
Abstract
Anemia is a multifactorial condition; approaches to address it must recognize that the causal factors represent an ecology consisting of internal (biology, genetics, and health) and external (social/behavioral/demographic and physical) environments. In this paper, we present an approach for selecting interventions, followed by a description of key issues related to the multiple available interventions for prevention and reduction of anemia. We address interventions for anemia using the following 2 main categories: 1) those that address nutrients alone, and, 2) those that address nonnutritional causes of anemia. The emphasis will be on interventions of public health relevance, but we also consider the clinical context. We also focus on interventions at different stages of the life course, with a particular focus on women of reproductive age and preschool-age children, and present evidence on various factors to consider when selecting an intervention-inflammation, genetic mutations, nutrient delivery, bioavailability, and safety. Each section on an intervention domain concludes with a brief discussion of key research areas.
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Affiliation(s)
- Cornelia U Loechl
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Ananya Datta-Mitra
- Department of Pathology and Laboratory Medicine, University of California, Davis, Davis, CA, United States
| | - Lindy Fenlason
- Bureau for Global Health, USAID, Washington, DC, United States
| | - Ralph Green
- Department of Pathology and Laboratory Medicine, University of California, Davis, Davis, CA, United States
| | - Laura Hackl
- USAID Advancing Nutrition, John Snow Inc., Arlington, VA, United States
| | - Laura Itzkowitz
- Bureau for Global Health, USAID, Washington, DC, United States
| | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Development, National Institutes of Health, Bethesda, MD, Unites States
| | - Denish Moorthy
- USAID Advancing Nutrition, John Snow Inc., Arlington, VA, United States.
| | | | - Helena Pachón
- Food Fortification Initiative, Emory University, Atlanta, GA, United States
| | - Nicole Stoffel
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Zu¨rich, Switzerland; MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Michael B Zimmerman
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Daniel J Raiten
- Eunice Kennedy Shriver National Institute of Child Health and Development, National Institutes of Health, Bethesda, MD, Unites States
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5
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Bahati Y, Nyanza EC, Asori M, Mutayoba R, Thomas DSK. Influence of intermittent iron and folic acid supplementation on cognitive abilities among adolescent girls in northwestern Tanzania. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002079. [PMID: 37851636 PMCID: PMC10584093 DOI: 10.1371/journal.pgph.0002079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/12/2023] [Indexed: 10/20/2023]
Abstract
Iron and folic acid (IFA) supplementation to reduce anemia is key for improving substantial lost disability adjusted life years (DALYs) for adolescent girls. This study assessed the impact of weekly IFA supplementation (WIFAS) on cognitive ability among adolescent girls in the Simiyu Region in northernwestern Tanzania. This cross-sectional comparative evaluation study of 770 adolescent girls (396 -WIFAS supplemented; 374 -not supplemented) evaluated the association between WIFAS and cognitive ability through a face-to-face survey and cognitive ability assessment using standardized tests (Span-forward Test, Span-backward Test and Maze Test). Using a modified Poisson regression, we controlled for the geographic setting (urban vs rural), availability of potable water and feeding programs in schools, age and school level of adolescent girls, parental status, main parental economic activities, and the number of teachers. Participants were between the ages of 11 and 19 years, with more than half (57%) between 12-15 years of age. Those with WIFAS had higher cognitive ability (Span-forward scores, χ2 = 46.34% p <0.001; Span-forward, χ2 = 46.34% p <0.001; and Global Composite Cognitive Performance (GCCP), χ2 = 32.52% p<0.001). Among the IFA supplemented adolescent girls, secondary school level had a significantly higher score with respect to Span-backward (aPR = 1.43, 95% CI = 1.06-1.62); Span-forward ability (aPR = 1.26, 95% CI = 1.04-1.53) and Maze Test ability (aPR = 1.12, 95% CI = 1.01-1.25) as compared to their counterpart in primary school level. Individual adolescent girls with WIFAS and living with both parents performed much better on the Span-backward Test (aPR = 1.22, 95% CI = 1.07-1.68) as compared to those living with relatives and/or orphans. The presence of potable water program among the WIFAS schools resulted in a higher Span-backward ability (aPR = 1.34, 95% CI = 1.03-1.89); and GCCP (aPR = 1.27, 95% CI = 1.03-1.75). Adolescent girls from WIFAS schools with feeding program had higher Span-forward (aPR = 1.38, 95% CI = 1.03-1.63) ability as well as a higher Maze Test (aPR = 1.15, 95% CI = 1.07-1.26) score. The present study provides compelling evidence that WIFAS is positively associated with higher cognitive ability among adolescent girls. Nevertheless, IFA interventions are still rare in communities across Tanzania.
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Affiliation(s)
- Yasinta Bahati
- Department of Environmental, Occupational, and Department of Environmental, Occupational Health, and GIS, School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
- Amref Health Africa and Nutrition International, Regional Health Management Team-Simiyu Region, Simiyu Region, Tanzania
| | - Elias C. Nyanza
- Department of Environmental, Occupational, and Department of Environmental, Occupational Health, and GIS, School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Moses Asori
- Department of Geography and Earth Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States of America
| | - Rita Mutayoba
- Amref Health Africa and Nutrition International, Regional Health Management Team-Simiyu Region, Simiyu Region, Tanzania
| | - Deborah S. K. Thomas
- Department of Geography and Earth Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States of America
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Mwangi MN, Mzembe G, Ngwira CC, Vokhiwa M, Kapulula MD, Larson LM, Braat S, Harding R, McLean ARD, Hamadani JD, Biggs BA, Ataíde R, Phiri KS, Pasricha SR. Protocol for a randomised, multicentre, four-arm, double-blinded, placebo-controlled trial to assess the benefits and safety of iron supplementation with malaria chemoprevention to children in Malawi: IRMA trial. BMJ Open 2023; 13:e069011. [PMID: 37832986 PMCID: PMC10583080 DOI: 10.1136/bmjopen-2022-069011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
INTRODUCTION Approximately 40% of children aged 6-59 months worldwide are anaemic. Iron-containing multiple micronutrient powders (MNPs) and iron supplements (syrup/drops) are used to combat anaemia in children in different parts of the world. However, evidence for functional benefits of iron supplementation in children is scarce, and potential risks remain poorly defined, particularly concerning diarrhoea and malaria. This trial aims to determine if: (1) the efficacy of iron supplements or MNPs (containing iron) given with malaria chemoprevention is superior to malaria chemoprevention alone, or (2) if the efficacy of malaria chemoprevention alone is superior to placebo on child cognitive development. METHODS AND ANALYSIS IRMA is a four-arm, parallel-group, double-blinded, placebo-controlled, triple-dummy, randomised trial in Southern Malawi. The study recruits 2168 infants aged 6 months, with an intervention period of 6 months and a post-intervention period of a further 6 months. Children are randomised into four arms: (1) No intervention (placebo); (2) malaria chemoprevention only; (3) MNPs and malaria chemoprevention; and (4) iron syrup and malaria chemoprevention. The primary outcome, cognitive development (Cognitive Composite Score (CogCS)), is measured at the end of the 6 months intervention. Secondary outcomes include CogCS at a further 6 months post-intervention, motor, language and behavioural development, physical growth and prevalence of anaemia and iron deficiency. Safety outcomes include incidence of malaria and other infections, and prevalence of malaria parasitaemia during and post-intervention period. ETHICS AND DISSEMINATION The trial is approved by the National Health Sciences Research Committee (#19/01/2213) (Malawi) and the Human Research Ethics Committee (WEHI: 19/012) (Australia). Written informed consent in the local language is obtained from each participant before conducting any study-related procedure. Results will be shared with the local community and internationally with academic and policy stakeholders. TRIAL REGISTRATION NUMBER ACTRN12620000386932.
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Affiliation(s)
- Martin N Mwangi
- Training and Research Unit of Excellence (TRUE), Blantyre, Malawi
- The Micronutrient Forum, Healthy Mothers Healthy Babies Consortium, Washington DC, Washington, USA
| | - Glory Mzembe
- Training and Research Unit of Excellence (TRUE), Blantyre, Malawi
- Department of Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Maclean Vokhiwa
- Training and Research Unit of Excellence (TRUE), Blantyre, Malawi
- Department of Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Leila M Larson
- Department of Health Promotion, Education, and Behaviour, University of South Carolina Arnold School of Public Health, Columbia, South Carolina, USA
| | - Sabine Braat
- Department of Infectious Diseases at the Peter Doherty Institute of Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, University of Melbourne School of Population and Global Health, Carlton, Victoria, Australia
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Rebecca Harding
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Alistair R D McLean
- Centre for Epidemiology and Biostatistics, University of Melbourne School of Population and Global Health, Carlton, Victoria, Australia
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Jena D Hamadani
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Beverley-Ann Biggs
- Department of Infectious Diseases at the Peter Doherty Institute of Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
- Diagnostic Haematology, The Royal Melbourne Hospital; and Clinical Haematology, Melbourne, Victoria, Australia
| | - Ricardo Ataíde
- Department of Infectious Diseases at the Peter Doherty Institute of Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Kamija S Phiri
- Training and Research Unit of Excellence (TRUE), Blantyre, Malawi
- Department of Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Diagnostic Haematology, The Royal Melbourne Hospital; and Clinical Haematology, Melbourne, Victoria, Australia
- Department of Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
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Adams KP, Vosti SA, Arnold CD, Engle-Stone R, Prado EL, Stewart CP, Wessells KR, Dewey KG. The cost-effectiveness of small-quantity lipid-based nutrient supplements for prevention of child death and malnutrition and promotion of healthy development: modelling results for Uganda. Public Health Nutr 2023; 26:2083-2095. [PMID: 37606091 PMCID: PMC10564609 DOI: 10.1017/s1368980023001805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 08/08/2023] [Accepted: 08/11/2023] [Indexed: 08/23/2023]
Abstract
OBJECTIVE Recent meta-analyses demonstrate that small-quantity lipid-based nutrient supplements (SQ-LNS) for young children significantly reduce child mortality, stunting, wasting, anaemia and adverse developmental outcomes. Cost considerations should inform policy decisions. We developed a modelling framework to estimate the cost and cost-effectiveness of SQ-LNS and applied the framework in the context of rural Uganda. DESIGN We adapted costs from a costing study of micronutrient powder (MNP) in Uganda, and based effectiveness estimates on recent meta-analyses and Uganda-specific estimates of baseline mortality and the prevalence of stunting, wasting, anaemia and developmental disability. SETTING Rural Uganda. PARTICIPANTS Not applicable. RESULTS Providing SQ-LNS daily to all children in rural Uganda (> 1 million) for 12 months (from 6 to 18 months of age) via the existing Village Health Team system would cost ∼$52 per child (2020 US dollars) or ∼$58·7 million annually. SQ-LNS could avert an average of > 242 000 disability-adjusted life years (DALYs) annually as a result of preventing 3689 deaths, > 160 000 cases of moderate or severe anaemia and ∼6000 cases of developmental disability. The estimated cost per DALY averted is $242. CONCLUSIONS In this context, SQ-LNS may be more cost-effective than other options such as MNP or the provision of complementary food, although the total cost for a programme including all age-eligible children would be high. Strategies to reduce costs, such as targeting to the most vulnerable populations and the elimination of taxes on SQ-LNS, may enhance financial feasibility.
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Affiliation(s)
- Katherine P Adams
- Institute for Global Nutrition, University of California, Davis, CA95616, USA
| | - Stephen A Vosti
- Department of Agricultural and Resource Economics, University of California, Davis, CA, USA
| | - Charles D Arnold
- Institute for Global Nutrition, University of California, Davis, CA95616, USA
| | - Reina Engle-Stone
- Institute for Global Nutrition, University of California, Davis, CA95616, USA
| | - Elizabeth L Prado
- Institute for Global Nutrition, University of California, Davis, CA95616, USA
| | - Christine P Stewart
- Institute for Global Nutrition, University of California, Davis, CA95616, USA
| | - K Ryan Wessells
- Institute for Global Nutrition, University of California, Davis, CA95616, USA
| | - Kathryn G Dewey
- Institute for Global Nutrition, University of California, Davis, CA95616, USA
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Pasricha SR, Moir-Meyer G. Measuring the global burden of anaemia. Lancet Haematol 2023; 10:e696-e697. [PMID: 37536354 DOI: 10.1016/s2352-3026(23)00171-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 06/05/2023] [Indexed: 08/05/2023]
Affiliation(s)
- Sant-Rayn Pasricha
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Diagnostic Haematology, The Royal Melbourne Hospital, Parkville, VIC, Australia; Clinical Haematology at The Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, VIC, Australia; Department of Medical Biology, The University of Melbourne, Parkville VIC, Australia.
| | - Gemma Moir-Meyer
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia
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Karthikappallil R, Atkinson SH. Universal iron supplementation: the best strategy to tackle childhood anaemia in malaria-endemic countries? Wellcome Open Res 2023; 8:345. [PMID: 37786779 PMCID: PMC10541535 DOI: 10.12688/wellcomeopenres.19750.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 10/04/2023] Open
Abstract
Iron deficiency presents a major public health concern in many malaria-endemic regions, and both conditions affect young children most severely. Daily iron supplementation is the standard public health intervention recommended to alleviate rates of iron deficiency in children, but there is controversy over whether universal supplementation could increase the incidence and severity of malaria infection. Current evidence suggests that iron supplementation of deficient individuals is safe and effective in high-transmission settings when accompanied by malaria prevention strategies. However, low-resource settings often struggle to effectively control the spread of malaria, and it remains unclear whether supplementation of iron replete individuals could increase their risk of malaria and other infections. This review explores the evidence for and against universal iron supplementation programmes, and alternative strategies that could be used to alleviate iron deficiency in malaria-endemic areas, while minimising potential harm.
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Affiliation(s)
- Roshan Karthikappallil
- Department of Paediatrics, University of Oxford, Oxford, England, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
| | - Sarah H. Atkinson
- Department of Paediatrics, University of Oxford, Oxford, England, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
- Kenya Medical Research Institute (KEMRI) Centre for Geographic Medicine Coast, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
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10
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Braat S, Fielding K, Han J, Jackson VE, Zaloumis S, Xu JXH, Moir-Meyer G, Blaauwendraad SM, Jaddoe VWV, Gaillard R, Parkin PC, Borkhoff CM, Keown-Stoneman CDG, Birken CS, Maguire JL, Bahlo M, Davidson E, Pasricha SR. Statistical haemoglobin thresholds to define anaemia across the lifecycle. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.22.23290129. [PMID: 37292786 PMCID: PMC10246131 DOI: 10.1101/2023.05.22.23290129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Detection of anaemia is critical for clinical medicine and public health. Current WHO values that define anaemia are statistical thresholds (5 th centile) set over 50 years ago, and are presently <110g/L in children 6-59 months, <115g/L in children 5-11 years, <110g/L in pregnant women, <120g/L in children 12-14 years of age, <120g/L in non-pregnant women, and <130g/L in men. Haemoglobin is sensitive to iron and other nutrient deficiencies, medical illness and inflammation, and is impacted by genetic conditions; thus, careful exclusion of these conditions is crucial to obtain a healthy reference population. We identified data sources from which sufficient clinical and laboratory information was available to determine an apparently healthy reference sample. Individuals were excluded if they had any clinical or biochemical evidence of a condition that may diminish haemoglobin concentration. Discrete 5 th centiles were estimated along with two-sided 90% confidence intervals and estimates combined using a fixed-effect approach. Estimates for the 5 th centile of the healthy reference population in children were similar between sexes. Thresholds in children 6-23 months were 104.4g/L [90% CI 103.5, 105.3]; in children 24-59 months were 110.2g/L [109.5, 110.9]; and in children 5-11 years were 114.1g/L [113.2, 115.0]. Thresholds diverged by sex in adolescents and adults. In females and males 12-17 years, thresholds were 122.2g/L [121.3, 123.1] and 128.2 [126.4, 130.0], respectively. In adults 18-65 years, thresholds were 119.7g/L [119.1, 120.3] in non-pregnant females and 134.9g/L [134.2, 135.6] in males. Limited analyses indicated 5 th centiles in first-trimester pregnancy of 110.3g/L [109.5, 111.0] and 105.9g/L [104.0, 107.7] in the second trimester. All thresholds were robust to variations in definitions and analysis models. Using multiple datasets comprising Asian, African, and European ancestries, we did not identify novel high prevalence genetic variants that influence haemoglobin concentration, other than variants in genes known to cause important clinical disease, suggesting non-clinical genetic factors do not influence the 5 th centile between ancestries. Our results directly inform WHO guideline development and provide a platform for global harmonisation of laboratory, clinical and public health haemoglobin thresholds.
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11
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Rojas-Roque C, Palacios A. A Systematic Review of Health Economic Evaluations and Budget Impact Analyses to Inform Healthcare Decision-Making in Central America. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:419-440. [PMID: 36720754 DOI: 10.1007/s40258-023-00791-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Little is known about the quality, quantity and disease areas analysed by health economic research that inform healthcare decision-making in Central America. This study aimed to review the existing health economic evaluations (HEEs) and budget impact analyses (BIAs) evidence in Central America based on scope and reporting quality. METHODS HEEs and BIAs published from 2000 to April 2021 were searched in five electronic databases: PubMed, Embase, LILACS (Latin American and Caribbean Health Science Literature), EconLIT and OVID Global Health. Two reviewers assessed titles, abstracts and full texts of studies for eligibility. The quality appraisal for the reporting was based on La Torre and colleagues' version of the Drummond checklist and the ISPOR good practices for BIA. For each country, we correlated the number of studies by disease area with their respective burden of disease to identify under-researched health areas. RESULTS 102 publications were eligible for this review. Ninety-four publications reported a HEE, six publications reported a BIA, and two studies reported both a HEE and a BIA. Costa Rica had the highest number of publications (n = 28, 27.5%), followed by Guatemala (n = 25, 24.5%). Cancer and respiratory infections were the most common types of disease studied. Diabetes mellitus, chronic kidney diseases, and mental disorders were under-researched relative to their disease burden in most of the countries. The overall mean quality reporting score for HEE and BIA studies were 71/119 points (60%) and 7/10 points (70%), respectively; however, these assessments were made on different scales. CONCLUSION In Central America, health economic research is sparse and is considered as suboptimal quality for reporting. The findings reported information useful to other low- and middle-income countries with similar advances in the application of economics to promote health policy decision-making.
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Affiliation(s)
- Carlos Rojas-Roque
- Health Technology Assessment and Health Economics Department, Institute for Clinical Effectiveness and Health Policy (IECS), Doctor Emilio Ravignani 2024, Buenos Aires, Argentina.
| | - Alfredo Palacios
- Health Technology Assessment and Health Economics Department, Institute for Clinical Effectiveness and Health Policy (IECS), Doctor Emilio Ravignani 2024, Buenos Aires, Argentina
- Facultad de Ciencias Económicas, Universidad de Buenos Aires, Buenos Aires, Argentina
- Centre for Health Economics (CHE), University of York, York, UK
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12
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Guo X, Feng C, Pu J, Jiang H, Zhu Z, Zheng Z, Zhang J, Chen G, Zhu J, Wu H. Deep Brain Stimulation for Advanced Parkinson Disease in Developing Countries: A Cost-Effectiveness Study From China. Neurosurgery 2023; 92:812-819. [PMID: 36729808 DOI: 10.1227/neu.0000000000002274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/29/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The cost-effectiveness of deep brain stimulation (DBS) is more favorable than best medical treatment (BMT) for advanced Parkinson disease (PD) in developed countries. However, it remains unclear in developing countries, where the cost of DBS may not be reimbursed by health care system. OBJECTIVE To model and evaluate the long-term cost-effectiveness of DBS for advanced PD in China from a patient payer perspective. METHODS We developed a Markov model representing the clinical progress of PD to predict the disease progression and related medical costs in a 15-year time horizon. The incremental cost-effectiveness ratio (ICER) and net benefit were used to evaluate the cost-effectiveness of DBS vs BMT. RESULTS DBS treatment led to discounted total costs of ¥370 768 ($56 515.20) (95% CI, ¥369 621.53-371 914.88), compared with ¥48 808 ($7439.68) (95% CI, ¥48 502.63-49 114.21) for BMT, with an additional 1.51 quality-adjusted life years gained, resulting in an ICER of ¥213 544 ($32 549.96)/quality-adjusted life years (95% CI, ¥208 177.35-218 910.10). Sensitivity analysis showed that DBS-related cost has the most substantial impact on ICER. Nation-wide net benefit of BMT and DBS were ¥33 819 ($5154.94) (95% CI, ¥30 211.24-37 426) and ¥30 361 ($4627.85) (95% CI, ¥25 587.03-39 433.66), respectively. Patient demographic analysis showed that more favorable DBS cost-effectiveness was associated with younger age and less severe disease stage. CONCLUSION DBS is cost-effective for patients with advanced PD over a 15-year time horizon in China. However, compared with developed countries, DBS remains a substantial economic burden for patients when no reimbursement is provided. Our findings may help inform cost-effectiveness-based decision making for clinical care of PD in developing countries.
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Affiliation(s)
- Xinxia Guo
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Chen Feng
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Jiali Pu
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Hongjie Jiang
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Zhoule Zhu
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Zhe Zheng
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Jianmin Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Gao Chen
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Junming Zhu
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Hemmings Wu
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
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13
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Larson LM, Feuerriegel D, Hasan MI, Braat S, Jin J, Tipu SMU, Shiraji S, Tofail F, Biggs BA, Hamadani JD, Johnson KA, Bode S, Pasricha SR. Effects of iron supplementation on neural indices of habituation in Bangladeshi children. Am J Clin Nutr 2023; 117:73-82. [PMID: 36789946 DOI: 10.1016/j.ajcnut.2022.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/23/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Iron deficiency and anemia have been associated with poor cognition in children, yet the effects of iron supplementation on neurocognition remain unclear. OBJECTIVE We aimed to examine the effects of supplementation with iron on neural indices of habituation using auditory event-related brain potentials (ERPs). METHODS This substudy was nested within a 3-arm, double-blind, double-dummy, individual randomized trial in Bangladesh, in which 3300 8-mo-old children were randomly selected to receive 3 mo of daily iron syrup (12.5 mg iron), multiple micronutrient powders (MNPs) (including 12.5 mg iron), or placebo. Children were assessed after 3 mo of intervention (mo 3) and 9 mo thereafter (mo 12). The neurocognitive substudy comprised a randomly selected subset of children from the main trial. Brain activity elicited during an auditory roving oddball task was recorded using electroencephalography to provide an index of habituation. The differential response to a novel (deviant) compared with a repeated (standard) sound was examined. The primary outcome was the amplitude of the mismatch response (deviant minusstandard tone waveforms) at mo 3. Secondary outcomes included the deviant and standard tone-evoked amplitudes, N2 amplitude differences, and differences in mean amplitudes evoked by deviant tones presented in the second compared with first half of the oddball sequence at mo 3 and 12. RESULTS Data were analyzed from 329 children at month 3 and 363 at mo 12. Analyses indicated no treatment effects of iron interventions compared with placebo on the amplitude of the mismatch response (iron syrup compared with placebo: mean difference (MD) = 0.07μV [95% CI: -1.22, 1.37]; MNPs compared with placebo: MD = 0.58μV [95% CI: -0.74, 1.90]) nor any secondary ERP outcomes at mo 3 or 12, despite improvements in hemoglobin and ferritin concentrations from iron syrup and MNPs in this nested substudy. CONCLUSION In Bangladeshi children with >40% anemia prevalence, iron or MNP interventions alone are insufficient to improve neural indices of habituation. This trial was registered at the Australian New Zealand Clinical Trials Registry as ACTRN12617000660381.
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Affiliation(s)
- Leila M Larson
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA; Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Department of Infectious Diseases at the Peter Doherty Institute, The University of Melbourne, Melbourne, VIC, Australia.
| | - Daniel Feuerriegel
- Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Mohammed Imrul Hasan
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Sabine Braat
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Department of Infectious Diseases at the Peter Doherty Institute, The University of Melbourne, Melbourne, VIC, Australia; Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Australia
| | - Jerry Jin
- Department of Infectious Diseases at the Peter Doherty Institute, The University of Melbourne, Melbourne, VIC, Australia; Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Sm Mulk Uddin Tipu
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Shamima Shiraji
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Fahmida Tofail
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Beverley-Ann Biggs
- Department of Infectious Diseases at the Peter Doherty Institute, The University of Melbourne, Melbourne, VIC, Australia; The Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jena D Hamadani
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Katherine A Johnson
- Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Stefan Bode
- Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Diagnostic Hematology, The Royal Melbourne Hospital, Parkville VIC, Australia; Diagnostic Hematology and Clinical Hematology, The Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville VIC, Australia; Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia
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14
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Wegmüller R, Bah A, Kendall L, Goheen MM, Sanyang S, Danso E, Sise EA, Jallow A, Verhoef H, Jallow MW, Wathuo M, Armitage AE, Drakesmith H, Pasricha SR, Cross JH, Cerami C, Prentice AM. Hepcidin-guided screen-and-treat interventions for young children with iron-deficiency anaemia in The Gambia: an individually randomised, three-arm, double-blind, controlled, proof-of-concept, non-inferiority trial. Lancet Glob Health 2023; 11:e105-e116. [PMID: 36521942 PMCID: PMC9764454 DOI: 10.1016/s2214-109x(22)00449-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 09/22/2022] [Accepted: 10/04/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Iron deficiency is the most prevalent nutritional disorder worldwide. Iron supplementation has modest efficacy, causes gastrointestinal side-effects that limit compliance, and has been associated with serious adverse outcomes in children across low-income settings. We aimed to compare two hepcidin-guided screen-and-treat regimens designed to reduce overall iron dosage by targeting its administration to periods when children were safe and ready to receive iron supplementation, with WHO's recommendation of universal iron supplementation. METHODS We conducted an individually randomised, three-arm, double-blind, controlled, proof-of-concept, non-inferiority trial in 12 rural communities across The Gambia. Eligible participants were children aged 6-23 months with anaemia. Participants were randomly assigned (1:1:1) to either the WHO recommended regimen of one sachet of multiple micronutrient powder (MMP) daily containing 12·0 mg iron as encapsulated ferrous fumarate (control group); to MMP with 12·0 mg per day iron for the next 7 days if plasma hepcidin concentration was less than 5·5 μg/L, or to MMP without iron for the next 7 days if plasma hepcidin concentration was at least 5·5 μg/L (12 mg screen-and-treat group); or to MMP with 6·0 mg per day iron for the next 7 days if plasma hepcidin concentration was less than 5·5 μg/L, or to MMP without iron for the next 7 days if plasma hepcidin concentration was at least 5·5 μg/L (6 mg screen-and-treat group). Randomisation was done by use of a permuted block design (block size of 9), with stratification by haemoglobin and age, using computer-generated numbers. Participants and the research team (except for the data manager) were masked to group allocation. The primary outcome was haemoglobin concentration, with a non-inferiority margin of -5 g/L. A per-protocol analysis, including only children who had consumed at least 90% of the supplements (ie, supplement intake on ≥75 days during the study), was done to assess non-inferiority of the primary outcome at day 84 using a one-sided t test adjusted for multiple comparisons. Safety was assessed by use of ex-vivo growth tests of Plasmodium falciparum in erythrocytes and three species of sentinel bacteria in plasma samples from participants. This trial is registered with the ISRCTN registry, ISRCTN07210906. FINDINGS Between April 23, 2014, and Aug 7, 2015, we prescreened 783 children, of whom 407 were enrolled into the study: 135 were randomly assigned to the control group, 136 to the 12 mg screen-and-treat group, and 136 to the 6 mg screen-and-treat group. 345 (85%) children were included in the per-protocol population: 115 in the control group, 116 in the 12 mg screen-and-treat group, and 114 in the 6 mg screen-and-treat group. Directly observed adherence was high across all groups (control group 94·8%, 12 mg screen-and-treat group 95·3%, and 6 mg screen-and-treat group 95·0%). 82 days of iron supplementation increased mean haemoglobin concentration by 7·7 g/L (95% CI 3·2 to 12·2) in the control group. Both screen-and-treat regimens were significantly less efficacious at improving haemoglobin (-5·6 g/L [98·3% CI -9·9 to -1·3] in the 12 mg screen-and-treat group and -7·8 g/L [98·3% CI -12·2 to -3·5] in the 6 mg screen-and-treat group) and neither regimen met the preset non-inferiority margin of -5 g/L. The 12 mg screen-and-treat regimen reduced iron dosage to 6·1 mg per day and the 6 mg screen-and-treat regimen reduced dosage to 3·0 mg per day. 580 adverse events were observed in 316 participants, of which eight were serious adverse events requiring hospitalisation mainly due to diarrhoeal disease (one [1%] participant in the control group, three [2%] in the 12 mg screen-and-treat group, and four [3%] in the 6 mg screen-and-treat group). The most common causes of non-serious adverse events (n=572) were diarrhoea (145 events [25%]), upper respiratory tract infections (194 [34%]), lower respiratory tract infections (62 [11%]), and skin infections (122 [21%]). No adverse events were deemed to be related to the study interventions. INTERPRETATION The hepcidin-guided screen-and-treat strategy to target iron administration succeeded in reducing overall iron dosage, but was considerably less efficacious at increasing haemoglobin and combating iron deficiency and anaemia than was WHO's standard of care, and showed no differences in morbidity or safety outcomes. FUNDING Bill & Melinda Gates Foundation and UK Medical Research Council.
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Affiliation(s)
- Rita Wegmüller
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia; GroundWork, Fläsch, Switzerland
| | - Amat Bah
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia; National Nutrition Agency, Bakau, The Gambia
| | - Lindsay Kendall
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Morgan M Goheen
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia; Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Saikou Sanyang
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Ebrima Danso
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Ebrima A Sise
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Amadou Jallow
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Hans Verhoef
- Wageningen University & Research, Wageningen, Netherlands
| | - Momodou W Jallow
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia; Regeneron Genetics Center, Tarrytown, NY, USA
| | - Miriam Wathuo
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia; One Acre Fund, Kigali, Rwanda
| | - Andrew E Armitage
- Medical Research Council Human Immunology Unit, Medical Research Council Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Hal Drakesmith
- Medical Research Council Human Immunology Unit, Medical Research Council Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Sant-Rayn Pasricha
- Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
| | - James H Cross
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Carla Cerami
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Andrew M Prentice
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia.
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15
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Prang KH, Mamani-Mategula E, Verbunt E, Chipeta E, Ataide R, Mwangi M, Phiri K, Pasricha SR, Kelaher M, Manda-Taylor L. An implementation research programme to support an intravenous iron intervention for pregnant women with moderate and severe anaemia in Malawi: study protocol. Implement Sci Commun 2022; 3:68. [PMID: 35729604 PMCID: PMC9210048 DOI: 10.1186/s43058-022-00299-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 04/24/2022] [Indexed: 12/03/2022] Open
Abstract
Background Antenatal iron supplementation is critical to maternal and child health; however, access and adherence to oral iron are inconsistent in many low- and middle-income countries (LMICs). Modern intravenous (IV) iron products have become available in high-income clinical settings and provide an opportunity to deliver high doses of iron in a single-short infusion during pregnancy. However, there is limited knowledge of the drivers and barriers for such an intervention to be effectively delivered and upscaled in LMICs. In this study protocol, we describe the implementation research programme to support an IV iron intervention in Malawi for pregnant women with moderate and severe anaemia. Methods The implementation research programme has three phases, each guided by implementation science conceptual frameworks. In Phase 1, we will conduct formative research (context assessment of the health system with key informant interviews) to determine how IV iron can be effectively introduced into routine antenatal care. We will use the findings to co-develop potential strategies with end-users and healthcare providers to improve intervention implementation. In Phase 2, we will disseminate the implementation strategies to support the uptake and delivery of the intervention in the study settings. In Phase 3, the intervention will be implemented, and we will conduct formative evaluation (interviews with end-users, healthcare providers, and analysis of health services data) to investigate the feasibility and acceptability of the intervention and strategies. We will also identify processes and contextual factors that facilitate or impede the delivery and uptake of IV iron. Discussion In LMICs, modern IV iron products present a novel opportunity to rapidly cure moderate and severe anaemia in pregnancy, thereby improving maternal and child health outcomes. This implementation research programme will provide guidance and recommendations on how best an IV iron intervention for pregnant women with anaemia can be implemented in an LMIC setting like Malawi. We will develop locally relevant and culturally appropriate implementation strategies by engaging with key stakeholders (pregnant women, healthcare providers, and policymakers) and identifying factors likely to facilitate successful implementation. The findings of this research can guide the implementation of an IV iron intervention in Malawi and other LMICs.
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16
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Engle-Stone R, Adams KP. Costs, cost-effectiveness, and context. Am J Clin Nutr 2022; 116:1193-1194. [PMID: 36191291 PMCID: PMC9630872 DOI: 10.1093/ajcn/nqac254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
| | - Katherine P Adams
- Institute for Global Nutrition, University of California, Davis, Davis, CA, USA,Department of Nutrition, University of California, Davis, Davis, CA, USA
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17
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Akpan E, Hossain SJ, Devine A, Braat S, Hasan MI, Tipu SMMU, Bhuiyan MSA, Hamadani JD, Biggs BA, Pasricha SR, Carvalho N. Cost-effectiveness of universal iron supplementation and iron-containing micronutrient powders for anemia among young children in rural Bangladesh: analysis of a randomized, placebo-controlled trial. Am J Clin Nutr 2022; 116:1303-1313. [PMID: 36192508 PMCID: PMC9630870 DOI: 10.1093/ajcn/nqac225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/05/2022] [Accepted: 08/17/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Universal provision of iron supplements or iron-containing multiple micronutrient powders (MNPs) is widely used to prevent anemia in young children in low- and middle-income countries. The BRISC (Benefits and Risks of Iron Interventions in Children) trial compared iron supplements and MNPs with placebo in children <2 y old in rural Bangladesh. OBJECTIVES We aimed to assess the cost-effectiveness of iron supplements or iron-containing MNPs among young children in rural Bangladesh. METHODS We did a cost-effectiveness analysis of MNPs and iron supplements using the BRISC trial outcomes and resource use data, and programmatic data from the literature. Health care costs were assessed from a health system perspective. We calculated incremental cost-effectiveness ratios (ICERs) in terms of US$ per disability-adjusted life-year (DALY) averted. To explore uncertainty, we constructed cost-effectiveness acceptability curves using bootstrapped data over a range of cost-effectiveness thresholds. One- and 2-way sensitivity analyses tested the impact of varying key parameter values on our results. RESULTS Provision of MNPs was estimated to avert 0.0031 (95% CI: 0.0022, 0.0041) DALYs/child, whereas iron supplements averted 0.0039 (95% CI: 0.0030, 0.0048) DALYs/child, over 1 y compared with no intervention. Incremental mean costs were $0.75 (95% CI: 0.73, 0.77) for MNPs compared with no intervention and $0.64 ($0.62, $0.67) for iron supplements compared with no intervention. Iron supplementation dominated MNPs because it was cheaper and averted more DALYs. Iron supplementation had an ICER of $1645 ($1333, $2153) per DALY averted compared with no intervention, and had a 0% probability of being the optimal strategy at cost-effectiveness thresholds of $200 (reflecting health opportunity costs in Bangladesh) and $985 [half of gross domestic product (GDP) per capita] per DALY averted. Scenario and sensitivity analyses supported the base case findings. CONCLUSIONS These findings do not support universal iron supplementation or micronutrient powders as a cost-effective intervention for young children in rural Bangladesh.This trial was registered at anzctr.org.au as ACTRN1261700066038 and trialsearch.who.int as U1111-1196-1125.
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Affiliation(s)
- Edifofon Akpan
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Sheikh J Hossain
- International Centre for Diarrhoeal Disease Research, Maternal and Child Health Division, Bangladesh (icddr,b), Dhaka, Bangladesh,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Angela Devine
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia,Division of Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Sabine Braat
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia,Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia,Department of Medicine at the Peter Doherty Institute, The University of Melbourne, Parkville, Victoria, Australia
| | - Mohammed I Hasan
- International Centre for Diarrhoeal Disease Research, Maternal and Child Health Division, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - S M Mulk Uddin Tipu
- International Centre for Diarrhoeal Disease Research, Maternal and Child Health Division, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammad Saiful Alam Bhuiyan
- International Centre for Diarrhoeal Disease Research, Maternal and Child Health Division, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Jena D Hamadani
- International Centre for Diarrhoeal Disease Research, Maternal and Child Health Division, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Beverley-Ann Biggs
- Department of Medicine at the Peter Doherty Institute, The University of Melbourne, Parkville, Victoria, Australia
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia,Diagnostic Hematology, The Royal Melbourne Hospital, Parkville, Victoria, Australia,Clinical Hematology, The Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, Victoria, Australia,Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia
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18
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Randell M, Li M, Rachmi CN, Jusril H, Fox O, Wibowo L, Rah JH, Pronyk P, Harmiko M, Phebe N, Ahmad A, Ariawan I, Negin J, Raynes-Greenow C. Prevalence of, and factors associated with anaemia in children aged 1-3 years in Aceh, Indonesia: A cross-sectional study. Nutr Health 2022:2601060221116195. [PMID: 35876347 DOI: 10.1177/02601060221116195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Background: Child anaemia continues to represent a major public health challenge in lower-and-middle income countries. It has serious long-term consequences for child growth and development. In Indonesia, there was a 10% increase in the national prevalence of child anaemia between 2013 and 2018. Aim: This study aims to assess the prevalence of, and factors associated with anaemia among children aged one to three years in eight districts in Aceh Province, Indonesia. Methods: A cross-sectional study was conducted on a sample of 1148 mother-child dyads aged one to three years between November and December 2018. The sampling process involved a three-stage cluster sampling design using the probability proportionate to size methodology. Anaemia status was determined using haemoglobin level (Hb < 11.0 g/dL). Data were analysed using multivariable logistic regression to estimate adjusted odds ratios (aOR) and their 95% confidence intervals (95% CI) for associated factors. Results: The overall prevalence of anaemia was 76.1% (869/1142). 44.7% (510/1142) and 28.6% (327/1142) had moderate and mild anaemia, respectively. Child aged 12-24 months (aOR: 2.00, 95% CI: 1.26-3.17), not receiving routine immunisation (aOR: 2.62, 95% CI: 1.34-5.10), and maternal anaemia (aOR: 2.15, 95% CI: 1.59-2.90) were significantly associated with anaemia. Conclusion: The prevalence of anaemia among the children in this study was high, and was associated with child age, immunisation status, and maternal anaemia. These findings provide further insight into anaemia as a public health issue at a sub-national level in Indonesia and for development of targeted programmes to address associated risk factors of child anaemia.
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Affiliation(s)
- Madeleine Randell
- Sydney School of Public Health, The University of Sydney, Camperdown, Australia
| | - Mu Li
- Sydney School of Public Health, The University of Sydney, Camperdown, Australia
| | | | | | - Olivia Fox
- Sydney School of Public Health, The University of Sydney, Camperdown, Australia
| | | | | | - Paul Pronyk
- SingHealth Duke-NUS Global Health Department, Singapore
| | | | | | - Aripin Ahmad
- Nutrition Department of 483792Aceh Health Polytechnic, Ministry of Health, Banda Aceh, Aceh, Indonesia
| | - Iwan Ariawan
- 608659Reconstra Utama Integra, Jakarta, Indonesia
| | - Joel Negin
- Sydney School of Public Health, The University of Sydney, Camperdown, Australia
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19
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Iron Status, Anemia, and Iron Interventions and Their Associations with Cognitive and Academic Performance in Adolescents: A Systematic Review. Nutrients 2022; 14:nu14010224. [PMID: 35011099 PMCID: PMC8746955 DOI: 10.3390/nu14010224] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 02/07/2023] Open
Abstract
In adolescents, iron-deficiency anemia is the leading cause of disability-adjusted life years lost. The World Health Organization recommends delivering iron supplementation through school-based platforms, requiring partnerships with the education sector. This anemia-reduction intervention is valued for the perceived benefits of improved learning and school performance. This article aims to systematically review the available evidence on the relationship between iron status and anemia and impacts of iron interventions on cognitive and academic performance in adolescents. Fifty studies were included: n = 26 cross-sectional and n = 24 iron-containing interventions. Our review suggests that iron status and anemia may be associated with academic performance in some contexts and that iron supplementation during adolescence may improve school performance, attention, and concentration. However, nearly all supplementation trials were judged to have moderate or high risk of bias. We did not find evidence suggesting that iron status and anemia influenced or were associated with attention, intelligence, nor memory in adolescents. Further, iron supplementation did not improve memory and recall or intelligence. Overall, more high-quality research is needed to guide programmers and policy makers to understand the relationships between anemia and educational performance and the potential impacts of iron interventions, which effectively reduce anemia, on adolescents’ learning and school performance.
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20
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Karamagi HC, Berhane A, Ngusbrhan Kidane S, Nyawira L, Ani-Amponsah M, Nyanjau L, Maoulana K, Seydi ABW, Nzinga J, Dangou JM, Nkurunziza T, K Bisoborwa G, Sillah JS, W Muriithi A, Nirina Razakasoa H, Bigirimana F. High impact health service interventions for attainment of UHC in Africa: A systematic review. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000945. [PMID: 36962639 PMCID: PMC10021619 DOI: 10.1371/journal.pgph.0000945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/23/2022] [Indexed: 11/19/2022]
Abstract
African countries have prioritized the attainment of targets relating to Universal Health Coverage (UHC), Health Security (HSE) and Coverage of Health Determinants (CHD)to attain their health goals. Given resource constraints, it is important to prioritize implementation of health service interventions with the highest impact. This is important to be identified across age cohorts and public health functions of health promotion, disease prevention, diagnostics, curative, rehabilitative and palliative interventions. We therefore explored the published evidence on the effectiveness of existing health service interventions addressing the diseases and conditions of concern in the Africa Region, for each age cohort and the public health functions. Six public health and economic evaluation databases, reports and grey literature were searched. A total of 151 studies and 357 interventions were identified across different health program areas, public health functions and age cohorts. Of the studies, most were carried out in the African region (43.5%), on communicable diseases (50.6%), and non-communicable diseases (36.4%). Majority of interventions are domiciled in the health promotion, disease prevention and curative functions, covering all age cohorts though the elderly cohort was least represented. Neonatal and communicable conditions dominated disease burden in the early years of life and non-communicable conditions in the later years. A menu of health interventions that are most effective at averting disease and conditions of concern across life course in the African region is therefore consolidated. These represent a comprehensive evidence-based set of interventions for prioritization by decision makers to attain desired health goals. At a country level, we also identify principles for identifying priority interventions, being the targeting of higher implementation coverage of existing interventions, combining interventions across all the public health functions-not focusing on a few functions, provision of subsidies or free interventions and prioritizing early identification of high-risk populations and communities represent these principles.
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Affiliation(s)
- Humphrey Cyprian Karamagi
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Araia Berhane
- Conmmunicable Diseases Control Division, Ministry of Health, Asmara, Eritrea
| | - Solyana Ngusbrhan Kidane
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Lizah Nyawira
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | | | - Koulthoume Maoulana
- Ministry of Health, Solidarity, Social Protection and Gender Promotion, Moroni, Comoros
| | - Aminata Binetou Wahebine Seydi
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
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21
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Dewey KG, Wessells KR, Arnold CD, Prado EL, Abbeddou S, Adu-Afarwuah S, Ali H, Arnold BF, Ashorn P, Ashorn U, Ashraf S, Becquey E, Bendabenda J, Brown KH, Christian P, Colford JM, Dulience SJL, Fernald LCH, Galasso E, Hallamaa L, Hess SY, Humphrey JH, Huybregts L, Iannotti LL, Jannat K, Lartey A, Le Port A, Leroy JL, Luby SP, Maleta K, Matias SL, Mbuya MNN, Mridha MK, Nkhoma M, Null C, Paul RR, Okronipa H, Ouédraogo JB, Pickering AJ, Prendergast AJ, Ruel M, Shaikh S, Weber AM, Wolff P, Zongrone A, Stewart CP. Characteristics that modify the effect of small-quantity lipid-based nutrient supplementation on child growth: an individual participant data meta-analysis of randomized controlled trials. Am J Clin Nutr 2021; 114:15S-42S. [PMID: 34590672 PMCID: PMC8560308 DOI: 10.1093/ajcn/nqab278] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 08/04/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Meta-analyses show that small-quantity lipid-based nutrient supplements (SQ-LNSs) reduce child stunting and wasting. Identification of subgroups who benefit most from SQ-LNSs may facilitate program design. OBJECTIVES We aimed to identify study-level and individual-level modifiers of the effect of SQ-LNSs on child growth outcomes. METHODS We conducted a 2-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age (n = 37,066). We generated study-specific and subgroup estimates of SQ-LNS compared with control and pooled the estimates using fixed-effects models. We used random-effects meta-regression to examine study-level effect modifiers. In sensitivity analyses, we examined whether results differed depending on study arm inclusion criteria and types of comparisons. RESULTS SQ-LNS provision decreased stunting (length-for-age z score < -2) by 12% (relative reduction), wasting [weight-for-length (WLZ) z score < -2] by 14%, low midupper arm circumference (MUAC) (<125 mm or MUAC-for-age z score < -2) by 18%, acute malnutrition (WLZ < -2 or MUAC < 125 mm) by 14%, underweight (weight-for-age z score < -2) by 13%, and small head size (head circumference-for-age z score < -2) by 9%. Effects of SQ-LNSs generally did not differ by study-level characteristics including region, stunting burden, malaria prevalence, sanitation, water quality, duration of supplementation, frequency of contact, or average compliance with SQ-LNS. Effects of SQ-LNSs on stunting, wasting, low MUAC, and small head size were greater among girls than among boys; effects on stunting, underweight, and low MUAC were greater among later-born (than among firstborn) children; and effects on wasting and acute malnutrition were greater among children in households with improved (as opposed to unimproved) sanitation. CONCLUSIONS The positive impact of SQ-LNSs on growth is apparent across a variety of study-level contexts. Policy-makers and program planners should consider including SQ-LNSs in packages of interventions to prevent both stunting and wasting.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592.
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Affiliation(s)
- Kathryn G Dewey
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - K Ryan Wessells
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Charles D Arnold
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Elizabeth L Prado
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Souheila Abbeddou
- Public Health Nutrition, Department of Public Health and Primary Care, University of Ghent, Ghent, Belgium
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Hasmot Ali
- The JiVitA Project of Johns Hopkins University, Bangladesh, Paschimpara, Bangladesh
| | - Benjamin F Arnold
- Francis I Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA
| | - Per Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Ulla Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sania Ashraf
- Center for Social Norms and Behavioral Dynamics, University of Pennsylvania, Philadelphia, PA, USA
| | - Elodie Becquey
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Jaden Bendabenda
- Department of Nutrition and Food Safety, WHO, Geneva, Switzerland
| | - Kenneth H Brown
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
- Helen Keller International, New York, NY, USA
| | - Parul Christian
- Program in Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - John M Colford
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | | | - Lia C H Fernald
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | | | - Lotta Hallamaa
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sonja Y Hess
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Jean H Humphrey
- Program in Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Lieven Huybregts
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Lora L Iannotti
- Brown School, Washington University in St. Louis, St Louis, MO, USA
| | - Kaniz Jannat
- School of Health Sciences, Western Sydney University, Penrith, New South Wales, Australia
| | - Anna Lartey
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | | | - Jef L Leroy
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Kenneth Maleta
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Susana L Matias
- Department of Nutritional Sciences and Toxicology, University of California, Berkeley, Berkeley, CA, USA
| | - Mduduzi N N Mbuya
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Global Alliance for Improved Nutrition, Washington, DC, USA
| | - Malay K Mridha
- Center for Non-communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, Dhaka, Bangladesh
| | - Minyanga Nkhoma
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Rina R Paul
- Center for Non-communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, Dhaka, Bangladesh
| | - Harriet Okronipa
- Department of Population Medicine and Diagnostic Sciences, Cornell University, Ithaca, NY, USA
| | | | | | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Marie Ruel
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Saijuddin Shaikh
- The JiVitA Project of Johns Hopkins University, Bangladesh, Paschimpara, Bangladesh
| | - Ann M Weber
- Division of Epidemiology, School of Community Health Sciences, University of Nevada, Reno, Reno, NV, USA
| | | | | | - Christine P Stewart
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
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Zlotkin S, Dewey KG. Perspective: Putting the youngest among us into the nutrition "call for action" for food fortification strategies. Am J Clin Nutr 2021; 114:1257-1260. [PMID: 34159356 PMCID: PMC8488864 DOI: 10.1093/ajcn/nqab207] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/01/2021] [Indexed: 02/05/2023] Open
Abstract
Adequate iron intake is essential for optimal child development, but iron deficiency and anemia among infants and young children are widespread in low- and middle-income countries. Large-scale food fortification strategies hold great promise for reducing micronutrient deficiencies; however, for children <2 y of age, the impact of such strategies is limited because their intake of staple foods is relatively low and fortification levels are targeted at the adult population. Iron supplementation, iron fortification of foods targeted to infants, and point-of-use fortification with iron-containing products such as multiple micronutrient powders (MNPs) and small-quantity lipid-based nutrient supplements are evidence-based approaches recommended to reduce anemia among infants and young children when used in the right context. Since 2003, the WHO, with support from UNICEF, has recommended the use of MNPs to control iron deficiency. However, the percentage of children with anemia has changed very little over the past 10 y. Five years ago the UN declared a decade of action on nutrition, including World Health Assembly (WHA) targets for maternal, infant, and young child nutrition, yet the WHA set no anemia targets for children. In July 2020 the leaders of 4 UN agencies issued a call for action to protect children's right to nutrition in the face of the COVID-19 pandemic and beyond. Given persistently high rates of anemia among young children, the negative developmental impact, the challenge of meeting iron needs from typical complementary food diets, and the availability of successful evidence-based fortification strategies for this age group, we encourage planners, speakers, and donors at this year's UN Food Systems Summit and the Tokyo Nutrition for Growth Summit to 1) call for the WHA to set anemia targets for infants and young children and 2) promote investment in evidence-based interventions to improve the iron status of young children.
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Affiliation(s)
- Stanley Zlotkin
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kathryn G Dewey
- Department of Nutrition, University of California, Davis, Davis, CA, USA
- Institute for Global Nutrition, University of California, Davis, Davis, CA, USA
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23
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Mwangi MN, Mzembe G, Moya E, Verhoef H. Iron deficiency anaemia in sub-Saharan Africa: a review of current evidence and primary care recommendations for high-risk groups. Lancet Haematol 2021; 8:e732-e743. [PMID: 34481549 DOI: 10.1016/s2352-3026(21)00193-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 06/01/2021] [Accepted: 06/10/2021] [Indexed: 11/19/2022]
Abstract
The epidemiology of iron deficiency anaemia in sub-Saharan Africa differs from that in other parts of the world. The low-quality diets prevalent in this region are a poor source of iron, the population is frequently exposed to infection, and demographic characteristics result in a greater prevalence of people at high risk of iron deficiency anaemia than in other parts of the world. We herein review the causes, disease burden, and consequences of iron deficiency anaemia in the general population in this region, and current policies and interventions for its control. The current debate is dominated by concerns about the safety of iron interventions, namely regarding its effects on malaria and other infectious diseases. However, universal antenatal iron supplementation and delayed cord clamping are safe interventions and stand out for their potential to improve maternal and infant health. Effective infection control is a precondition to safe and efficacious iron interventions in children. Greater emphasis should be given to approaches aiming to reduce iron loss due to helminth infections and menstruation, alongside interventions to increase iron intake. TRANSLATION: For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Martin N Mwangi
- Training and Research Unit of Excellence, Blantyre, Malawi; School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi.
| | - Glory Mzembe
- Training and Research Unit of Excellence, Blantyre, Malawi; School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Ernest Moya
- Training and Research Unit of Excellence, Blantyre, Malawi; School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Hans Verhoef
- Division of Human Nutrition and Health, Wageningen University, Wageningen, Netherlands; MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
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24
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Baek Y, Ademi Z, Paudel S, Fisher J, Tran T, Romero L, Owen A. Economic Evaluations of Child Nutrition Interventions in Low- and Middle-Income Countries: Systematic Review and Quality Appraisal. Adv Nutr 2021; 13:282-317. [PMID: 34510178 PMCID: PMC8803532 DOI: 10.1093/advances/nmab097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/24/2021] [Accepted: 07/27/2021] [Indexed: 11/12/2022] Open
Abstract
Economic evaluation is crucial for cost-effective resource allocation to improve child nutrition in low and middle-income countries (LMICs). However, the quality of published economic evaluations in these settings is not well understood. This systematic review aimed to assess the quality of existing economic evaluations of child nutrition interventions in LMICs and synthesize the study characteristics and economic evidence. We searched 9 electronic databases, including MEDLINE, with the following concepts: economic evaluation, children, nutrition, and LMICs. All types of interventions addressing malnutrition, including stunting, wasting, micronutrient deficiency, and overweight, were identified. We included economic evaluations that examined both costs and effects published in English peer-reviewed journals and used the Drummond checklist for quality appraisal. We present findings through a narrative synthesis. Sixty-nine studies with diverse settings, perspectives, time horizons, and outcome measures were included. Most studies used data from sub-Saharan Africa and South Asia and addressed undernutrition. The mortality rate, intervention effect, intervention coverage, cost, and discount rate were reported as predictors among studies that performed sensitivity analyses. Despite the heterogeneity of included studies and the possibility of publication bias, 81% of included studies concluded that nutrition interventions were cost-effective or cost-beneficial, mostly based on a country's cost-effectiveness thresholds. Regarding quality assessment, the studies published after 2016 met more criteria than studies published before 2016. Most studies had well-stated research questions, forms of economic evaluation, interventions, and conclusions. However, reporting the perspective of the analyses, justification of discount rates, and describing the role of funders and ethics approval were identified as areas needing improvement. The gaps in the quality of reporting could be improved by consolidated guidance on the publication of economic evaluations and the use of appropriate quality appraisal checklists. Strengthening the evidence base for child malnutrition across different regions is necessary to inform cost-effective investment in LMICs. Trial registration: PROSPERO CRD42020194445.
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Affiliation(s)
- Yeji Baek
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Zanfina Ademi
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Susan Paudel
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jane Fisher
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Thach Tran
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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25
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Pasricha SR, Hasan MI, Braat S, Larson LM, Tipu SMMU, Hossain SJ, Shiraji S, Baldi A, Bhuiyan MSA, Tofail F, Fisher J, Grantham-McGregor S, Simpson JA, Hamadani JD, Biggs BA. Benefits and Risks of Iron Interventions in Infants in Rural Bangladesh. N Engl J Med 2021; 385:982-995. [PMID: 34496174 DOI: 10.1056/nejmoa2034187] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Universal provision of iron supplements (drops or syrup) or multiple micronutrient powders to young children in low-to-middle-income countries where anemia is prevalent is recommended by the World Health Organization and widely implemented. The functional benefits and safety of these interventions are unclear. METHODS We conducted a three-group, double-blind, double-dummy, individually randomized, placebo-controlled trial to assess the immediate and medium-term benefits and risks of 3 months of daily supplementation with iron syrup or iron-containing multiple micronutrient powders, as compared with placebo, in 8-month-old children in rural Bangladesh. The primary outcome was cognitive development, as assessed by the cognitive composite score on the Bayley Scales of Infant and Toddler Development, third edition, immediately after completion of the assigned 3-month regimen; scores range from 55 to 145, with higher scores indicating better cognitive performance. Secondary outcomes included the cognitive composite score at 9 months after completion of the assigned regimen; behavioral, language, and motor development, as well as growth and hematologic markers, immediately after completion and at 9 months after completion; and safety. RESULTS We randomly assigned 3300 infants to receive iron syrup (1101 infants), multiple micronutrient powders (1099), or placebo (1100) daily. After completion of the assigned 3-month regimen, no apparent effect on the cognitive composite score was observed with iron syrup as compared with placebo (mean between-group difference in change in score from baseline, -0.30 points; 95% confidence interval [CI], -1.08 to 0.48) or with multiple micronutrient powders as compared with placebo (mean between-group difference in change in score from baseline, 0.23 points; 95% CI, -0.55 to 1.00). No apparent effect on any other developmental or growth outcome was observed immediately after completion of the assigned regimen or at 9 months after completion. At 9 months after completion of the assigned regimen, the prevalences of anemia, iron deficiency, and iron deficiency anemia increased in all three trial groups but remained lower among the children who received iron syrup or multiple micronutrient powders than among those who received placebo. The risk of serious adverse events and incidence of symptoms of infection were similar in the three trial groups. CONCLUSIONS In this trial involving infants in Bangladesh, 3 months of daily supplementation with iron syrup or multiple micronutrient powders did not appear to have an effect on child development or other functional outcomes as compared with placebo. (Funded by the National Health and Medical Research Council of Australia; BRISC Australian New Zealand Clinical Trials Registry number, ACTRN12617000660381.).
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Affiliation(s)
- Sant-Rayn Pasricha
- From the Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research (S.-R.P., S.B., L.M.L., A.B.), Diagnostic Haematology, Royal Melbourne Hospital (S.-R.P.), Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital (S.-R.P.), the Department of Medical Biology (S.-R.P., A.B.), the Departments of Medicine and Infectious Diseases, Peter Doherty Institute for Infection and Immunity (S.B., L.M.L., B.-A.B.), and the Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health (S.B., J.A.S.), University of Melbourne, and the Victorian Infectious Diseases Service, Royal Melbourne Hospital (B.-A.B.), Parkville, VIC, and the Department of Public Health and Preventive Medicine, Monash University, Melbourne, VIC (J.F.) - all in Australia; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (M.I.H., S.M.M.U.T., S.J.H., S.S., M.S.A.B., F.T., J.D.H.); the Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia (L.M.L.); and the Institute of Child Health, University College London, London (S.G.-M.)
| | - M Imrul Hasan
- From the Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research (S.-R.P., S.B., L.M.L., A.B.), Diagnostic Haematology, Royal Melbourne Hospital (S.-R.P.), Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital (S.-R.P.), the Department of Medical Biology (S.-R.P., A.B.), the Departments of Medicine and Infectious Diseases, Peter Doherty Institute for Infection and Immunity (S.B., L.M.L., B.-A.B.), and the Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health (S.B., J.A.S.), University of Melbourne, and the Victorian Infectious Diseases Service, Royal Melbourne Hospital (B.-A.B.), Parkville, VIC, and the Department of Public Health and Preventive Medicine, Monash University, Melbourne, VIC (J.F.) - all in Australia; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (M.I.H., S.M.M.U.T., S.J.H., S.S., M.S.A.B., F.T., J.D.H.); the Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia (L.M.L.); and the Institute of Child Health, University College London, London (S.G.-M.)
| | - Sabine Braat
- From the Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research (S.-R.P., S.B., L.M.L., A.B.), Diagnostic Haematology, Royal Melbourne Hospital (S.-R.P.), Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital (S.-R.P.), the Department of Medical Biology (S.-R.P., A.B.), the Departments of Medicine and Infectious Diseases, Peter Doherty Institute for Infection and Immunity (S.B., L.M.L., B.-A.B.), and the Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health (S.B., J.A.S.), University of Melbourne, and the Victorian Infectious Diseases Service, Royal Melbourne Hospital (B.-A.B.), Parkville, VIC, and the Department of Public Health and Preventive Medicine, Monash University, Melbourne, VIC (J.F.) - all in Australia; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (M.I.H., S.M.M.U.T., S.J.H., S.S., M.S.A.B., F.T., J.D.H.); the Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia (L.M.L.); and the Institute of Child Health, University College London, London (S.G.-M.)
| | - Leila M Larson
- From the Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research (S.-R.P., S.B., L.M.L., A.B.), Diagnostic Haematology, Royal Melbourne Hospital (S.-R.P.), Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital (S.-R.P.), the Department of Medical Biology (S.-R.P., A.B.), the Departments of Medicine and Infectious Diseases, Peter Doherty Institute for Infection and Immunity (S.B., L.M.L., B.-A.B.), and the Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health (S.B., J.A.S.), University of Melbourne, and the Victorian Infectious Diseases Service, Royal Melbourne Hospital (B.-A.B.), Parkville, VIC, and the Department of Public Health and Preventive Medicine, Monash University, Melbourne, VIC (J.F.) - all in Australia; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (M.I.H., S.M.M.U.T., S.J.H., S.S., M.S.A.B., F.T., J.D.H.); the Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia (L.M.L.); and the Institute of Child Health, University College London, London (S.G.-M.)
| | - S M Mulk-Uddin Tipu
- From the Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research (S.-R.P., S.B., L.M.L., A.B.), Diagnostic Haematology, Royal Melbourne Hospital (S.-R.P.), Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital (S.-R.P.), the Department of Medical Biology (S.-R.P., A.B.), the Departments of Medicine and Infectious Diseases, Peter Doherty Institute for Infection and Immunity (S.B., L.M.L., B.-A.B.), and the Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health (S.B., J.A.S.), University of Melbourne, and the Victorian Infectious Diseases Service, Royal Melbourne Hospital (B.-A.B.), Parkville, VIC, and the Department of Public Health and Preventive Medicine, Monash University, Melbourne, VIC (J.F.) - all in Australia; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (M.I.H., S.M.M.U.T., S.J.H., S.S., M.S.A.B., F.T., J.D.H.); the Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia (L.M.L.); and the Institute of Child Health, University College London, London (S.G.-M.)
| | - Sheikh J Hossain
- From the Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research (S.-R.P., S.B., L.M.L., A.B.), Diagnostic Haematology, Royal Melbourne Hospital (S.-R.P.), Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital (S.-R.P.), the Department of Medical Biology (S.-R.P., A.B.), the Departments of Medicine and Infectious Diseases, Peter Doherty Institute for Infection and Immunity (S.B., L.M.L., B.-A.B.), and the Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health (S.B., J.A.S.), University of Melbourne, and the Victorian Infectious Diseases Service, Royal Melbourne Hospital (B.-A.B.), Parkville, VIC, and the Department of Public Health and Preventive Medicine, Monash University, Melbourne, VIC (J.F.) - all in Australia; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (M.I.H., S.M.M.U.T., S.J.H., S.S., M.S.A.B., F.T., J.D.H.); the Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia (L.M.L.); and the Institute of Child Health, University College London, London (S.G.-M.)
| | - Shamima Shiraji
- From the Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research (S.-R.P., S.B., L.M.L., A.B.), Diagnostic Haematology, Royal Melbourne Hospital (S.-R.P.), Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital (S.-R.P.), the Department of Medical Biology (S.-R.P., A.B.), the Departments of Medicine and Infectious Diseases, Peter Doherty Institute for Infection and Immunity (S.B., L.M.L., B.-A.B.), and the Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health (S.B., J.A.S.), University of Melbourne, and the Victorian Infectious Diseases Service, Royal Melbourne Hospital (B.-A.B.), Parkville, VIC, and the Department of Public Health and Preventive Medicine, Monash University, Melbourne, VIC (J.F.) - all in Australia; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (M.I.H., S.M.M.U.T., S.J.H., S.S., M.S.A.B., F.T., J.D.H.); the Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia (L.M.L.); and the Institute of Child Health, University College London, London (S.G.-M.)
| | - Andrew Baldi
- From the Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research (S.-R.P., S.B., L.M.L., A.B.), Diagnostic Haematology, Royal Melbourne Hospital (S.-R.P.), Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital (S.-R.P.), the Department of Medical Biology (S.-R.P., A.B.), the Departments of Medicine and Infectious Diseases, Peter Doherty Institute for Infection and Immunity (S.B., L.M.L., B.-A.B.), and the Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health (S.B., J.A.S.), University of Melbourne, and the Victorian Infectious Diseases Service, Royal Melbourne Hospital (B.-A.B.), Parkville, VIC, and the Department of Public Health and Preventive Medicine, Monash University, Melbourne, VIC (J.F.) - all in Australia; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (M.I.H., S.M.M.U.T., S.J.H., S.S., M.S.A.B., F.T., J.D.H.); the Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia (L.M.L.); and the Institute of Child Health, University College London, London (S.G.-M.)
| | - Mohammad S A Bhuiyan
- From the Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research (S.-R.P., S.B., L.M.L., A.B.), Diagnostic Haematology, Royal Melbourne Hospital (S.-R.P.), Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital (S.-R.P.), the Department of Medical Biology (S.-R.P., A.B.), the Departments of Medicine and Infectious Diseases, Peter Doherty Institute for Infection and Immunity (S.B., L.M.L., B.-A.B.), and the Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health (S.B., J.A.S.), University of Melbourne, and the Victorian Infectious Diseases Service, Royal Melbourne Hospital (B.-A.B.), Parkville, VIC, and the Department of Public Health and Preventive Medicine, Monash University, Melbourne, VIC (J.F.) - all in Australia; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (M.I.H., S.M.M.U.T., S.J.H., S.S., M.S.A.B., F.T., J.D.H.); the Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia (L.M.L.); and the Institute of Child Health, University College London, London (S.G.-M.)
| | - Fahmida Tofail
- From the Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research (S.-R.P., S.B., L.M.L., A.B.), Diagnostic Haematology, Royal Melbourne Hospital (S.-R.P.), Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital (S.-R.P.), the Department of Medical Biology (S.-R.P., A.B.), the Departments of Medicine and Infectious Diseases, Peter Doherty Institute for Infection and Immunity (S.B., L.M.L., B.-A.B.), and the Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health (S.B., J.A.S.), University of Melbourne, and the Victorian Infectious Diseases Service, Royal Melbourne Hospital (B.-A.B.), Parkville, VIC, and the Department of Public Health and Preventive Medicine, Monash University, Melbourne, VIC (J.F.) - all in Australia; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (M.I.H., S.M.M.U.T., S.J.H., S.S., M.S.A.B., F.T., J.D.H.); the Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia (L.M.L.); and the Institute of Child Health, University College London, London (S.G.-M.)
| | - Jane Fisher
- From the Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research (S.-R.P., S.B., L.M.L., A.B.), Diagnostic Haematology, Royal Melbourne Hospital (S.-R.P.), Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital (S.-R.P.), the Department of Medical Biology (S.-R.P., A.B.), the Departments of Medicine and Infectious Diseases, Peter Doherty Institute for Infection and Immunity (S.B., L.M.L., B.-A.B.), and the Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health (S.B., J.A.S.), University of Melbourne, and the Victorian Infectious Diseases Service, Royal Melbourne Hospital (B.-A.B.), Parkville, VIC, and the Department of Public Health and Preventive Medicine, Monash University, Melbourne, VIC (J.F.) - all in Australia; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (M.I.H., S.M.M.U.T., S.J.H., S.S., M.S.A.B., F.T., J.D.H.); the Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia (L.M.L.); and the Institute of Child Health, University College London, London (S.G.-M.)
| | - Sally Grantham-McGregor
- From the Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research (S.-R.P., S.B., L.M.L., A.B.), Diagnostic Haematology, Royal Melbourne Hospital (S.-R.P.), Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital (S.-R.P.), the Department of Medical Biology (S.-R.P., A.B.), the Departments of Medicine and Infectious Diseases, Peter Doherty Institute for Infection and Immunity (S.B., L.M.L., B.-A.B.), and the Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health (S.B., J.A.S.), University of Melbourne, and the Victorian Infectious Diseases Service, Royal Melbourne Hospital (B.-A.B.), Parkville, VIC, and the Department of Public Health and Preventive Medicine, Monash University, Melbourne, VIC (J.F.) - all in Australia; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (M.I.H., S.M.M.U.T., S.J.H., S.S., M.S.A.B., F.T., J.D.H.); the Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia (L.M.L.); and the Institute of Child Health, University College London, London (S.G.-M.)
| | - Julie A Simpson
- From the Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research (S.-R.P., S.B., L.M.L., A.B.), Diagnostic Haematology, Royal Melbourne Hospital (S.-R.P.), Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital (S.-R.P.), the Department of Medical Biology (S.-R.P., A.B.), the Departments of Medicine and Infectious Diseases, Peter Doherty Institute for Infection and Immunity (S.B., L.M.L., B.-A.B.), and the Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health (S.B., J.A.S.), University of Melbourne, and the Victorian Infectious Diseases Service, Royal Melbourne Hospital (B.-A.B.), Parkville, VIC, and the Department of Public Health and Preventive Medicine, Monash University, Melbourne, VIC (J.F.) - all in Australia; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (M.I.H., S.M.M.U.T., S.J.H., S.S., M.S.A.B., F.T., J.D.H.); the Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia (L.M.L.); and the Institute of Child Health, University College London, London (S.G.-M.)
| | - Jena D Hamadani
- From the Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research (S.-R.P., S.B., L.M.L., A.B.), Diagnostic Haematology, Royal Melbourne Hospital (S.-R.P.), Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital (S.-R.P.), the Department of Medical Biology (S.-R.P., A.B.), the Departments of Medicine and Infectious Diseases, Peter Doherty Institute for Infection and Immunity (S.B., L.M.L., B.-A.B.), and the Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health (S.B., J.A.S.), University of Melbourne, and the Victorian Infectious Diseases Service, Royal Melbourne Hospital (B.-A.B.), Parkville, VIC, and the Department of Public Health and Preventive Medicine, Monash University, Melbourne, VIC (J.F.) - all in Australia; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (M.I.H., S.M.M.U.T., S.J.H., S.S., M.S.A.B., F.T., J.D.H.); the Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia (L.M.L.); and the Institute of Child Health, University College London, London (S.G.-M.)
| | - Beverley-Ann Biggs
- From the Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research (S.-R.P., S.B., L.M.L., A.B.), Diagnostic Haematology, Royal Melbourne Hospital (S.-R.P.), Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital (S.-R.P.), the Department of Medical Biology (S.-R.P., A.B.), the Departments of Medicine and Infectious Diseases, Peter Doherty Institute for Infection and Immunity (S.B., L.M.L., B.-A.B.), and the Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health (S.B., J.A.S.), University of Melbourne, and the Victorian Infectious Diseases Service, Royal Melbourne Hospital (B.-A.B.), Parkville, VIC, and the Department of Public Health and Preventive Medicine, Monash University, Melbourne, VIC (J.F.) - all in Australia; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (M.I.H., S.M.M.U.T., S.J.H., S.S., M.S.A.B., F.T., J.D.H.); the Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia (L.M.L.); and the Institute of Child Health, University College London, London (S.G.-M.)
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26
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Drakesmith H, Pasricha SR, Cabantchik I, Hershko C, Weiss G, Girelli D, Stoffel N, Muckenthaler MU, Nemeth E, Camaschella C, Klenerman P, Zimmermann MB. Vaccine efficacy and iron deficiency: an intertwined pair? Lancet Haematol 2021; 8:e666-e669. [PMID: 34450104 PMCID: PMC8384343 DOI: 10.1016/s2352-3026(21)00201-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/27/2021] [Accepted: 06/30/2021] [Indexed: 01/19/2023]
Abstract
Vaccines are the most effective measure to prevent deaths and illness from infectious diseases. Nevertheless, the efficacy of several paediatric vaccines is lower in low-income and middle-income countries (LMICs), where mortality from vaccine-preventable infections remains high. Vaccine efficacy can also be decreased in adults in the context of some common comorbidities. Identifying and correcting the specific causes of impaired vaccine efficacy is of substantial value to global health. Iron deficiency is the most common micronutrient deficiency worldwide, affecting more than 2 billion people, and its prevalence in LMICs could increase as food security is threatened by the COVID-19 pandemic. In this Viewpoint, we highlight evidence showing that iron deficiency limits adaptive immunity and responses to vaccines, representing an under-appreciated additional disadvantage to iron deficient populations. We propose a framework for urgent detailed studies of iron-vaccine interactions to investigate and clarify the issue. This framework includes retrospective analysis of newly available datasets derived from trials of COVID-19 and other vaccines, and prospective testing of whether nutritional iron interventions, commonly used worldwide to combat anaemia, improve vaccine performance.
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Affiliation(s)
- Hal Drakesmith
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK; Haematology Theme, Oxford Biomedical Research Centre, Oxford, UK.
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Diagnostic Haematology, The Royal Melbourne Hospital, Parkville, VIC, Australia; Clinical Haematology, The Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, VIC, Australia; Department of Medical Biology, The University of Melbourne, Parkville, VIC, Australia
| | - Ioav Cabantchik
- Institute of Life Sciences, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Chaim Hershko
- Internal Medicine, Hadassah Medical School, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Guenter Weiss
- Department of Internal Medicine II, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, Innsbruck, Austria
| | - Domenico Girelli
- Department of Medicine, Section of Internal Medicine, University of Verona, Verona, Italy
| | - Nicole Stoffel
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Martina U Muckenthaler
- Department of Pediatric Hematology, Oncology and Immunology, University of Heidelberg, Heidelberg, Germany; Molecular Medicine Partnership Unit, Heidelberg, Germany
| | - Elizabeta Nemeth
- Center for Iron Disorders, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Clara Camaschella
- Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milano, Italy
| | - Paul Klenerman
- Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, UK; Oxford NIHR Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Michael B Zimmermann
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK; Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
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27
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Engle-Stone R. The role of modelling to inform context-specific anaemia programming. LANCET GLOBAL HEALTH 2020; 8:e982-e983. [PMID: 32710870 DOI: 10.1016/s2214-109x(20)30301-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/03/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Reina Engle-Stone
- Department of Nutrition and Institute for Global Nutrition, University of California, Davis, CA 95616, USA.
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